Community Engagement Survey

Thank you for participating in the community engagement survey. The purpose of this survey is to identify the barriers preventing older Americans from community engagement. This survey is completely voluntary and the responses you provide will remain anonymous.

Following completion of the survey, you will have the option to enter your name and phone number to be entered in to win prizes.

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* 1. Are you male or female?

Male

Female

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* 2. What is your age as of your last birthday?

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* 3. What is your 5-digit ZIP code?

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* 4. What is your current marital status?

Married

Not married, living with partner

Seperated

Divorced

Widowed

Never married

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* 5. Besides yourself, do you have any of the following people living in your household? Select all that apply.

Child/children under 18

Child/children 18 or older

Child/children away at college

Other adult relative or friend 18 or older

None

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* 6. Does any disability, handicap, or chronic disease keep you and/or your spouse or partner from fully participating in work, school, housework or other activities?

Yes, myself

Yes, my spouse or partner

Yes, both me and my spouse or partner

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* 7. What is your primary language?

English

Spanish

Italian

Chinese

Japanese

Ukrainian

Other (please specify)

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* 8. What is your race and/or ethnicity? [CHECK ALL THAT APPLY]

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

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* 9. Are you registered to vote?

Yes

No, but I would like to register

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* 10. How often do you use the internet to access your email, news, online banking, or other platforms such as Facebook?

Every day

3-6 days a week

1-2 days a week

Once every few weeks

Once a month or less

Never use the internet

I do not have access to the internet

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* 11. What was your annual household income before taxes in the most recent tax year?

Less than $10,000

$10,000 to $19,999

$20,000 to $29,999

$30,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 or more

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* 12. How would you rate your community as a place for people to live as they age?(This would be the geographical location where your home is located. A community can be located within a city or town or county.)

Very good

Good

Fair

Poor

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* 13. How long have you lived in this community?

Less than 5 years

5 to 15 years

15 to 25 years

25 to 35 years

35 years or more

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* 14. Thinking about your retirement years when you do not work at all for pay, how likely is it that you will move outside of your community?

Very likely

Likely

Somewhat likely

Somewhat unlikely

Unlikely

Very unlikely

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* 15. If you were to consider moving out of your community during your retirement, which of the following factors would impact your decision to move? Select all that apply.

Looking for a different home size that meets your needs

Maintaining your current home will be too expensive

Fearing for your personal safety or security concerns

Looking for a home that will help you live independently as you age

Wanting to move to an area that has better health care facilities

Wanting to be closer to family

Needing more access to public transportation

Looking for an area that has a lower cost of living

Other (please specify)

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* 16. Do you own or rent your primary home — or do you have some other type of living arrangement, such as living with a family member or friend?

Own

Rent

Other type of living arrangement

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* 17. What type of home is your primary home?

Single family home

Mobile home

Townhome or duplex

Apartment

Condominium

Other (please specify)

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* 18. How important is it for you to be able to live independently in your own home as you age?

Very important

Somewhat important

Not at all important

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* 19. What type of home do you wish to live in as you age?

Single family home

Mobile home

Townhome or duplex

Apartment

Condominium

Other (please specify)

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* 20. People sometimes make modifications to their home so they can stay there as they age. Do you think you will need to make the following types of modifications or improvements to your home to enable you to stay there as you age?

	Yes	No	Not sure
Easier access into or within your home such as a ramp, chairlift or elevator, or wider doorways	Easier access into or within your home such as a ramp, chairlift or elevator, or wider doorways Yes	Easier access into or within your home such as a ramp, chairlift or elevator, or wider doorways No	Easier access into or within your home such as a ramp, chairlift or elevator, or wider doorways Not sure
Bathroom modifications such as grab bars, handrails, a higher toilet or non-slip tiles	Bathroom modifications such as grab bars, handrails, a higher toilet or non-slip tiles Yes	Bathroom modifications such as grab bars, handrails, a higher toilet or non-slip tiles No	Bathroom modifications such as grab bars, handrails, a higher toilet or non-slip tiles Not sure
Putting a bedroom, bathroom and kitchen on the first floor	Putting a bedroom, bathroom and kitchen on the first floor Yes	Putting a bedroom, bathroom and kitchen on the first floor No	Putting a bedroom, bathroom and kitchen on the first floor Not sure
Improving lighting	Improving lighting Yes	Improving lighting No	Improving lighting Not sure
Installing a medical emergency response system that notifies others in case of emergency	Installing a medical emergency response system that notifies others in case of emergency Yes	Installing a medical emergency response system that notifies others in case of emergency No	Installing a medical emergency response system that notifies others in case of emergency Not sure

Other (please specify)

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* 21. Select the top three housing needs that you think are important to have in the community:

Home repair contractors who are trustworthy, do quality work and are affordable

Well-maintained homes and properties

A home repair service for low-income and older adults that helps with repairs

Affordable housing options for adults of varying income levels such as older active adult communities, assisted living and communities with shared facilities and outdoor spaces

Homes that are equipped with features such as a no-step entry, wider doorways, first floor bedroom and bath, grab bars in bathrooms

Well-maintained and safe low-income housing

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* 22. Are you able to participate in activities outside of your home?

Yes

Yes, with help

No, but I am interested in getting help

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* 23. How do you get around for activities such as shopping, visiting the doctor, running errands or going to other places? Select all that apply.

Drive yourself

Have others drive you

Walk

Ride a bike

Use public transportation

Take a taxi/cab

Other (please specify)

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* 24. Does the community where you live have the following?

	Yes	No	Not sure
Accessible and reliable public transportation	Accessible and reliable public transportation Yes	Accessible and reliable public transportation No	Accessible and reliable public transportation Not sure
Special transportation services for people with disabilities and older adults	Special transportation services for people with disabilities and older adults Yes	Special transportation services for people with disabilities and older adults No	Special transportation services for people with disabilities and older adults Not sure
Bus shelters to protect passengers during waiting time	Bus shelters to protect passengers during waiting time Yes	Bus shelters to protect passengers during waiting time No	Bus shelters to protect passengers during waiting time Not sure

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* 25. In general, when compared to most people your age, how would you rate your health?

Very good

Good

Fair

Poor

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* 26. How often do you engage in some form of physical exercise (such as walking, running, biking, swimming, sports, strength training, yoga, stretching)?

Every day

A few times a week

About once a week

A few times a month

Once a month

Less than once a month

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* 27. How important do you think it is to have the following in your community?

	Very important	Somewhat important	Not important
Health, wellness, and fitness programs and classes in areas such as nutrition, smoking cessation, and weight control	Health, wellness, and fitness programs and classes in areas such as nutrition, smoking cessation, and weight control Very important	Health, wellness, and fitness programs and classes in areas such as nutrition, smoking cessation, and weight control Somewhat important	Health, wellness, and fitness programs and classes in areas such as nutrition, smoking cessation, and weight control Not important
A service that helps seniors find and access health and supportive services	A service that helps seniors find and access health and supportive services Very important	A service that helps seniors find and access health and supportive services Somewhat important	A service that helps seniors find and access health and supportive services Not important
Home care services including health, personal care and housekeeping	Home care services including health, personal care and housekeeping Very important	Home care services including health, personal care and housekeeping Somewhat important	Home care services including health, personal care and housekeeping Not important
A variety of health care professionals including specialists	A variety of health care professionals including specialists Very important	A variety of health care professionals including specialists Somewhat important	A variety of health care professionals including specialists Not important
Health care professionals who speak different languages	Health care professionals who speak different languages Very important	Health care professionals who speak different languages Somewhat important	Health care professionals who speak different languages Not important

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* 28. How often do you interact with your friends, family or neighbors in your community via phone, in person, email or Facebook?

Every day

A few times a week

About once a week

A few times a month

Once a month

Less than once a month

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* 29. How important do you think it is to have the following in your community?

	Very important	Somewhat important	Not important
Activities specifically geared to older adults	Activities specifically geared to older adults Very important	Activities specifically geared to older adults Somewhat important	Activities specifically geared to older adults Not important
Local schools that involve older adults in events and activities	Local schools that involve older adults in events and activities Very important	Local schools that involve older adults in events and activities Somewhat important	Local schools that involve older adults in events and activities Not important
Social clubs such as for books, gardening, crafts or hobbies	Social clubs such as for books, gardening, crafts or hobbies Very important	Social clubs such as for books, gardening, crafts or hobbies Somewhat important	Social clubs such as for books, gardening, crafts or hobbies Not important

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* 30. How likely are you to engage in volunteering and civic engagement? (1 being the lowest and 5 being the highest)

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* 31. What volunteering opportunities would you want to see most in your community?

Opportunities for older adults to participate in decision making bodies such as community councils or committees

A range of volunteer activities to choose from

Volunteer training opportunities to help people perform better in their volunteer roles

Easy to find information about local volunteer opportunities

Other (please specify)

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* 32. Select the top three programs you would be interested in.

Healthy cooking for one or two

Exercise-Chair Yoga

Civic Engagement

Self-defense class

Painting, ceramics, pottery

Pet Therapy

Bonesavers (exercise program)

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* 33. How likely is it that you will choose to continue to work for pay rather than retire and no longer work for pay?

Likely

Somewhat likely

Somewhat unlikely

Unlikely

I do not have a job to retire from

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* 34. Which resources would you turn towards if you, a family member or friend needed information about services for older adults, such as caregiving services, home delivered meals, home repair, medical transport or social activities? Select all that apply.

Local senior centers

Local Area Agency on Aging (AAA)

Family or Friends

Local nonprofit organizations

Faith-based organizations such as churches or synagogues

Internet (Facebook, Email, etc..)

Your doctor or other health care professional

Local government offices such as the Department of Health

Library

Newspaper/Radio

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* 35. How aware are you about the programs and activities offered in your community?

Extremely aware

Very aware

Somewhat aware

Not so aware

Not at all aware

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* 36. Does the community where you live have the following?

	Yes	No	Not sure
Free access to computers and the Internet in public places such as the library, senior centers or government buildings	Free access to computers and the Internet in public places such as the library, senior centers or government buildings Yes	Free access to computers and the Internet in public places such as the library, senior centers or government buildings No	Free access to computers and the Internet in public places such as the library, senior centers or government buildings Not sure
Community information that is delivered in person to people who may have difficulty or may not be able to leave their home	Community information that is delivered in person to people who may have difficulty or may not be able to leave their home Yes	Community information that is delivered in person to people who may have difficulty or may not be able to leave their home No	Community information that is delivered in person to people who may have difficulty or may not be able to leave their home Not sure
Community information that is available in a number of different languages	Community information that is available in a number of different languages Yes	Community information that is available in a number of different languages No	Community information that is available in a number of different languages Not sure

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* 37. Optional: Please include your information to be entered to win one of the grand prize survey incentives.

Name

Phone Number